Doctors Medication Order Template for Campers

Doctors Medication Order Template for Campers
Camper Information
Camper Name
First NameLast Name
Age
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Weight (kg)
Height (cm)
Email
example@example.com
Phone Number
Area CodePhone Number
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Parent/Guardian Information
Parent/Guardian 1 Name
First NameLast Name
Phone Number
Area CodePhone Number
Relationship
Parent/Guardian 2 Name
First NameLast Name
Phone Number
Area CodePhone Number
Relationship
Current Data and Medical History

Kindly fill up the form below

Rows	Yes/No	Description/Remarks
Does the camper have any known allergies? If yes, then please specify in the Description field.
Is he/she currently taking any medications? If yes, then please list the medications and the reasons why the camper are taking them.
What is the current medical condition of the camper? Does he have any communicable disease, cardiovascular problems, diabetes, asthma, etc.?
Was the camper ever been hospitalized? If yes, please indicate why and when.
Did the camper undergo any previous surgery? If yes, please indicate the procedure name, reason, and the date.
Learning disabilities
Emotional or behavioral problems
Is the immunization up to date?

Medication Order
Rows Medication Name Schedule Dosage Route Reason/Purpose
1
2
3
4
5
6
7
8
9
10
Physician Name
First NameLast Name
Physician Phone Number
Area CodePhone Number
Physician Signature
Date Signed
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Note: All doctor's prescription order should be given to the health care team.
Select the following over the counter medications that can be given t the camper as nedded
Who will administer the medications?
Should be Empty:

Camper Information